Ignite Medical Hanover Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Hanover Park, Illinois.
- Location
- 2000 West Lake Street, Hanover Park, Illinois 60133
- CMS Provider Number
- 146143
- Inspections on file
- 29
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ignite Medical Hanover Park during CMS and state inspections, most recent first.
Surveyors found that several inhalers in use for four residents were open and not labeled with open or discard dates, despite facility policy and active medication orders. Nursing staff confirmed the lack of labeling during medication cart checks, and the DON acknowledged that all medications should be labeled as required.
Two residents were found self-administering medications without proper assessment or physician orders, including one using an inhaler for COPD and another taking bismuth subsalicylate for heartburn. Staff confirmed that no assessments or orders were in place, and facility policy requiring such assessments was not followed.
A resident with upper extremity contractures and multiple diagnoses, including multiple sclerosis and dementia, was not consistently provided with prescribed carrot hand splints or passive range of motion (PROM) exercises as documented in their care plan and physician orders. Despite clear instructions and task assignments for CNAs, the splints were not observed in use during most surveyor visits, and the resident reported that staff did not apply the splints or perform hand exercises.
Nursing staff failed to administer medications as ordered, including omitting a scheduled nasal spray due to unavailability, giving an incorrect dose of a supplement, not instructing a resident to rinse after inhaler use, and administering an antihypertensive without checking blood pressure as required. These actions resulted in a medication error rate exceeding 10%.
A resident with a history of falls and traumatic brain injury did not receive updated fall prevention interventions after experiencing a fall in the facility. Staff and family reported that no new safety measures were put in place, and the resident was observed in unsafe conditions, such as having the bed left elevated. Facility policies requiring post-fall assessment and intervention were not followed.
A resident with severe protein-calorie malnutrition and multiple comorbidities experienced significant weight loss and did not consistently receive a twice-daily nutritional supplement as ordered. Despite documentation on the MAR indicating the supplement was given, both the resident and staff confirmed it was often missed, and the resident was unaware of the daily order. Staff cited issues such as running out of the preferred flavor and admitted to not always administering the supplement.
A resident with a history of transient ischemic attack and brain aneurysm was given oxygen at 5 L/M with an empty humidifier bottle, despite a physician order for 2 L/M and facility policy requiring humidification. Staff confirmed the discrepancies in oxygen flow rate and humidifier use.
Several residents did not receive their prescribed medications, including DuoNeb, Hydrocodone-Acetaminophen, Flonase, Midodrine, Nystatin, Triamcinolone Acetonide, Diclofenac, Guaifenesin-Codeine, and Insulin Aspart, due to the facility's failure to reorder these medications before supplies were depleted. Nursing staff and the DON confirmed that medications were expected to be reordered in advance, but this did not occur, resulting in missed doses.
A resident in an LTC facility was not changed in a timely manner, leading to soaked incontinence briefs and skin excoriation. Despite the resident's call light being activated and staff acknowledging the need for timely changes, the facility was short-staffed, resulting in a delay. The resident required substantial assistance with toileting and had existing skin damage, highlighting the importance of adhering to the facility's ADL policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with wounds, as staff did not wear gowns or gloves during care. Despite orders for EBP, there were no signs or PPE outside the residents' rooms, contrary to the facility's policy.
The facility failed to provide adequate assistance with ADLs, particularly in eating and showering. Residents were unable to reach their breakfast trays, leading to missed meals, and did not receive showers as frequently as scheduled. The facility's policies on ADLs, meal service, and bathing were not effectively implemented, resulting in unmet care needs.
The facility failed to administer and document scheduled medications as ordered and did not reorder prescribed medications for several residents. An RN completed a morning medication pass without proper documentation, believing she was following a liberalized policy that was not applicable. Additionally, multiple residents did not have their prescribed medications available, including pain relief gels, insulin, and blood thinners. One resident did not receive scheduled doses of Xanax and Cefepime due to unavailability, despite the facility's policy requiring pharmacy notification of shortages.
A resident with type 2 diabetes had her blood glucose level checked by an LPN immediately after eating breakfast, contrary to the prescribed schedule of before meals and at bedtime. This resulted in a high reading and confusion for the resident, who understood the proper timing for such tests. The facility's policy and care plan were not followed, leading to a deficiency in care.
A facility failed to promptly respond to call lights, affecting six residents needing ADL assistance. Instances included a resident waiting over 20 minutes post-surgery for help, and another with a 10-minute delay while staff conversed. The Resident Council repeatedly raised concerns, yet no improvements were made. Family grievances highlighted neglect, with one resident found in a soiled state after a 20-minute wait. The facility's call light policy was not effectively followed, leading to care deficiencies.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs. One resident was unable to reach her call light, which was hanging over a dividing wall, while another resident's call light was found on the floor under her bed. Both residents are cognitively intact and require assistance with activities. The facility's policy requires staff to ensure call lights are accessible, but this was not adhered to in these cases.
A resident reported that her heating and air conditioning unit and over bed light had been broken for at least eight weeks, despite multiple notifications to staff. The Director of Environmental Services was unaware of the issues, and the facility's Work Order Report showed that the problems were reported on five occasions but not addressed in a timely manner.
A facility failed to refer a resident for a Level II PASARR evaluation after the resident was diagnosed with a new mental disorder. The resident was initially admitted with Type 2 Diabetes Mellitus and later diagnosed with a Psychotic Disorder and Major Depressive Disorder. Despite these new diagnoses, the facility did not initiate a Level II PASARR evaluation, as required by their policy. Interviews revealed staff confusion about the necessity of a Level II PASARR following new mental illness diagnoses after admission.
A facility failed to follow professional standards during blood glucose monitoring for two residents with type 2 diabetes. An RN used alcohol wipes instead of gauze to clean the first drop of blood, contrary to facility policy, potentially leading to inaccurate readings. The Director of Nursing acknowledged previous in-servicing on the correct procedure.
A resident at high risk for falls fell while attempting to transfer to the toilet after her call light went unanswered for an hour. She injured her right hip during the fall. The facility's DON and Administrator stated that residents should receive timely assistance, but the resident's needs were not met, violating the facility's fall prevention policy.
A resident experienced unmanaged severe pain due to a lapse in receiving prescribed Percocet medication, resulting in a pain level of 10 out of 10. The resident went over 24 hours without the medication, despite being regularly administered 5-6 doses daily. The facility's records showed a gap of over 27 hours between doses, and the resident was given acetaminophen for severe pain, contrary to its intended use for mild pain. The facility's pain management policy was not effectively implemented, leading to this deficiency.
A resident's personal refrigerator contained expired yogurt and moldy ham and cheese, despite the facility's policy requiring staff to check and remove expired food. The resident, who is cognitively intact, was unaware of the expired items, believing staff checked the refrigerator daily.
A facility failed to provide proper incontinence care, with multiple residents found wearing two briefs instead of one, against policy. Staff inconsistencies and lack of documentation in care plans contributed to this deficiency, affecting residents with various medical conditions requiring substantial assistance.
A resident with diabetes and other health conditions did not receive insulin as prescribed, leading to uncontrolled blood glucose levels. Insulin was administered after meals instead of before, and doses were given late, contrary to the physician's orders. The facility's policies on medication administration were not followed, resulting in significant medication errors.
Failure to Label Opened Inhalers with Open or Discard Dates
Penalty
Summary
Surveyors observed that multiple residents' inhaler medications, including Advair, Albuterol, Trelegy, and Breyna, were found open and not labeled with either open or discard dates on various medication carts throughout the facility. These observations were made in the presence of nursing staff, including both LPNs and RNs, who confirmed that the inhalers were open and lacked the required labeling. The residents involved had active physician orders for these inhalers, and the medications were in use at the time of the survey. The Director of Nursing confirmed that facility policy requires all medications, including inhalers, to be labeled with open dates to ensure safe storage and use, in accordance with manufacturer or supplier recommendations. Despite this policy, the survey found that the labeling procedure was not followed for the inhalers in question, resulting in a failure to comply with accepted professional principles for medication storage and labeling.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for the ability to self-administer medications, as evidenced by two residents who were found to be self-administering medications without proper assessment or physician orders. One resident, who had a diagnosis of chronic obstructive pulmonary disease, was observed using an albuterol inhaler provided by the facility without a documented order to self-administer or store the medication at bedside. The resident's care plan and records did not indicate any assessment or approval for self-administration of medication. Another resident was found with a bottle of bismuth subsalicylate at her bedside, which she reported taking for heartburn and had brought from home. There was no physician order for this medication or for self-administration, and no assessment had been completed to determine her ability to self-administer. Staff interviews confirmed that residents were not allowed to self-administer medications without an assessment and physician order, and that medications found at bedside would be removed. The facility's policy requires an assessment and physician order for self-administration, but this process was not followed for the two residents involved.
Failure to Provide Prescribed Splinting and Restorative Care for Contracture Management
Penalty
Summary
A deficiency was identified when a resident with contractures in both hands was not consistently provided with the prescribed carrot hand splints intended to prevent further worsening of contractures. During multiple observations over three days, the resident was found in bed without the carrot splints in place, except for one instance. The resident reported that staff never put the splints on or provided hand exercises. The care plan, physician orders, and occupational therapy recommendations all specified the use of bilateral carrot splints for up to eight hours daily, with skin integrity checks before and after use. The facility's electronic records and task lists for CNAs also documented the requirement for passive range of motion (PROM) exercises and splint use as part of the resident's restorative care. Despite these documented requirements, the splints were not observed on the resident during most surveyor visits, and the resident confirmed a lack of consistent application and exercises. The LPN/Restorative Nurse acknowledged that CNAs were responsible for providing restorative care and applying the splints, but this was not being carried out as ordered. The resident's diagnoses included multiple sclerosis, dementia, and other conditions contributing to upper extremity impairment, making adherence to the prescribed interventions critical for contracture management.
Medication Administration Errors and Noncompliance with Physician Orders
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.53% (4 errors out of 38 opportunities) during a medication pass observed by surveyors. In one instance, a registered nurse did not administer a resident's scheduled dose of Flonase nasal spray at 9 AM because it was unavailable, despite an active order for the medication. The omission was confirmed through review of the resident's electronic medication administration record (EMAR) and order summary report. Another resident received the incorrect dosage of Calcium Carbonate, being given 500 mg instead of the ordered 600 mg, and was not instructed to rinse her mouth after using a Breyna inhaler as required by the medication's instructions to prevent oral fungal infection. Additionally, a third resident was administered Amlodipine, an antihypertensive medication, without the nurse checking the resident's blood pressure prior to administration, contrary to the physician's order to hold the medication if systolic blood pressure was less than 90. The facility's policy requires that all medications be administered safely and according to physician orders.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate safety measures for a resident with a history of falls and traumatic brain injury. The resident, who was admitted from the hospital after a fall resulting in a brain bleed, also had multiple diagnoses including pneumonia, difficulty walking, lack of coordination, COPD, diabetes, congestive heart failure, hypertension, and kidney failure. Despite the resident's known fall risk and a recent fall within the facility, no new fall interventions were put in place after the incident. Family members expressed concern that no visible safety devices or interventions had been added, and staff interviews confirmed that no updates were made to the resident's care plan or interventions following the fall. Observations revealed that the resident's bed was left in an elevated position with his feet hanging off the side, and staff needed to be called to reposition him safely. Staff members, including CNAs and RNs, were unaware of any new fall interventions and did not reference a care card for safety measures. The DON acknowledged that the resident's prior fall history should have been included in the initial assessment and that interventions such as keeping the bed in a low position and offering assistance after meals were not consistently implemented. Facility policies required assessment and intervention after each fall, but these were not followed for this resident.
Failure to Provide Ordered Nutritional Supplement for Resident with Weight Loss
Penalty
Summary
A resident with a history of severe protein-calorie malnutrition, spinal infarction, paraplegia, stage 2 chronic kidney disease, neurogenic bowel and bladder, congestive heart failure, hypertension, atrial fibrillation, obstructive sleep apnea, coronary artery disease, and depression experienced a significant weight loss of 26 pounds (13.3%) over six months. The resident was cognitively intact and independent with eating. Despite a physician's order for a house supplement (such as Ensure or Boost) twice daily starting in late February, the resident reported not receiving the supplement for over a month and was unaware it was supposed to be provided daily. Interviews with nursing staff confirmed that the supplement was not consistently given, with one LPN admitting to not providing it that morning and an RN unable to recall the last time it was administered. Staff also indicated that the preferred flavor was sometimes unavailable, and the supplement was not always provided as ordered. The Medication Administration Record (MAR) for April showed staff, including the LPN and RN, were signing off that the supplement was given, despite the resident's statements and staff admissions that it was not consistently provided. The resident's care plan and progress notes documented the need for nutritional supplementation to address the risk of further weight loss. Facility policy required investigation and intervention for significant weight loss, but the failure to provide the ordered supplement as documented contributed to the resident's ongoing nutritional risk.
Failure to Follow Physician Orders and Proper Oxygen Administration Procedures
Penalty
Summary
The facility failed to follow physician orders and care plan interventions for a resident requiring oxygen therapy. A female resident with a history of transient ischemic attack and brain aneurysm was observed receiving oxygen via nasal cannula at 5 liters per minute (L/M), despite a physician order and care plan specifying oxygen at 2 L/M to maintain oxygen saturation above 92%. Additionally, the resident's oxygen was administered with an empty humidifier bottle, contrary to facility policy and staff statements that the humidifier should be filled with distilled water to prevent drying of the nares. Staff interviews confirmed the humidifier was empty and that the oxygen flow rate did not match the physician's order.
Failure to Reorder and Provide Prescribed Medications
Penalty
Summary
The facility failed to ensure the timely reordering and availability of prescribed medications for multiple residents. During observations and record reviews, it was found that one resident did not have access to their ordered DuoNeb and Hydrocodone-Acetaminophen, as confirmed by a registered nurse who reconciled the resident's medication orders with the medications on hand. Another resident missed a scheduled dose of Flonase nasal spray, and upon further review, it was determined that Flonase, Midodrine, Nystatin, and Triamcinolone Acetonide were not available for administration as prescribed. A third resident was also found to be without several ordered medications, including Diclofenac, DuoNeb, Guaifenesin-Codeine, and Insulin Aspart, as verified by a registered nurse through reconciliation of the order summary and available medications. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for nurses to reorder medications before supplies were depleted to ensure continuous availability for administration. The facility's policy on medication availability requires staff to inform the pharmacy of shortages or limited supplies. Despite these policies, the prescribed medications for the affected residents were not reordered in a timely manner, resulting in their unavailability at the time of administration.
Failure to Timely Change Incontinence Briefs
Penalty
Summary
The facility failed to ensure timely changing of incontinence briefs for a resident, identified as R3, who was unable to perform activities of daily living independently. On the morning of December 9, R3's call light was activated, and she reported needing her wet diaper changed, stating she had been wet since early morning. Despite her call light being answered once, no staff returned to assist her for over an hour. When a CNA finally arrived to change her, R3's brief, disposable pad, and cloth draw sheet were found to be soaked with urine, and her buttocks were red and excoriated. The facility's staff, including a CNA and the Director of Nursing, acknowledged the need for timely changes when residents are wet. However, the CNA mentioned that they were short-staffed on the day of the incident. R3's admission record indicated she required substantial assistance with toileting hygiene and was at risk for skin integrity issues, with existing moisture-associated skin damage. The facility's policy mandates that activities of daily living, such as changing incontinence briefs, should be adequately met, which was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) for three residents who required such measures due to their medical conditions. Observations revealed that there were no signs indicating isolation needs on the doors of the residents' rooms, and no personal protective equipment (PPE) was available outside their rooms. Specifically, one resident with amputated toes that got infected, another with a surgical incision on her leg, and a third with a bandaged leg wound were not provided with the necessary EBP, as staff did not wear gowns or gloves during care activities. The Infection Prevention Nurse confirmed that staff are required to wear gowns and gloves when providing activities of daily living care to residents on EBP, especially those with open wounds or external devices. Despite orders for EBP being in place for these residents, the facility did not adhere to its own policy, which mandates gown and glove use during high-contact care activities. The facility's Enhanced Barrier Precautions List included these residents, yet the necessary precautions were not observed during the survey.
Deficiencies in ADL Assistance and Shower Schedule
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, specifically in the areas of eating and showering. Observations revealed that residents were unable to reach their breakfast trays, resulting in missed meals. For instance, one resident was found in bed with an untouched breakfast tray out of reach, expressing hunger and difficulty in locating utensils due to visual impairment. Another resident, who was confused and non-interviewable, was also unable to reach her breakfast tray, which remained untouched. These instances indicate a lack of proper setup and assistance for residents who require help with eating. Additionally, the facility did not adhere to its shower schedule, as several residents reported not receiving showers as frequently as planned. One resident mentioned not having a shower for two weeks, while another had not received a shower in 18 days. The facility's policy states that residents should receive showers twice a week, yet documentation and resident interviews revealed inconsistencies in following this schedule. This lack of adherence to the care plan resulted in residents not receiving the necessary hygiene care. The facility's policies on ADLs, meal service, and bathing were not effectively implemented, leading to deficiencies in resident care. The Director of Nursing acknowledged the need for assistance with eating to ensure residents receive warm food and meet their nutritional needs. However, the observed practices did not align with the facility's policies, resulting in unmet care needs for residents requiring assistance with ADLs.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to administer and document scheduled medications as ordered for residents, as well as reorder prescribed medications. During an observation, a registered nurse (RN) was found to have completed her morning medication pass without documenting the administration of 9 AM medications for several residents. The RN believed she was following a liberalized medication administration policy, which was not applicable to medications with increased frequencies. The facility's policy required a physician order for liberalized medication administration, which was not present for the residents in question. Additionally, the facility failed to ensure the availability of prescribed medications for several residents. During a reconciliation of electronic medication administration records (EMARs) with available medications, it was found that multiple residents did not have their prescribed medications available, including pain relief gels, insulin, and blood thinners. The facility's policy required informing the pharmacy of medication shortages, which was not adhered to, resulting in residents not receiving their medications as ordered. One resident, who had been admitted with diagnoses including anxiety and a urinary tract infection, did not receive scheduled doses of Xanax and Cefepime due to unavailability. Progress notes indicated that the medications were not administered on multiple occasions because they were not available. The Assistant Director of Nursing (ADON) acknowledged that nurses had access to a medication convenience box and were expected to follow up with the pharmacy to ensure medication availability, which was not done in this case.
Failure to Monitor Blood Glucose Levels as Ordered
Penalty
Summary
The facility failed to monitor a resident's blood glucose level as ordered, which led to a deficiency in the quality of care provided. The resident, who has a diagnosis of type 2 diabetes and is cognitively intact, was supposed to have her blood glucose levels checked before meals and at bedtime. However, on one occasion, a Licensed Practical Nurse (LPN) checked the resident's blood glucose level right after she finished eating breakfast, resulting in a high reading of 270 mg/dL. The resident, who is Spanish-speaking, attempted to explain to the LPN that the timing of the test was inappropriate, as blood glucose levels should not be checked immediately after eating. The resident expressed confusion about why her blood glucose was checked post-meal, despite her understanding of diabetes management. The facility's policy and the resident's care plan both indicated that blood glucose monitoring should occur before meals and at bedtime, yet this was not adhered to. The facility's meal service schedule also showed that breakfast was served later than when the test was conducted, further indicating a deviation from the prescribed monitoring schedule. This oversight in following the physician's orders and care plan led to the deficiency noted in the report.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to promptly respond to residents' call lights, impacting six residents who required assistance with activities of daily living (ADLs). On multiple occasions, call lights were left unanswered for extended periods, leaving residents without necessary assistance. For instance, one resident, who had undergone recent foot surgery and required a mechanical lift for mobility, waited over 20 minutes for assistance after filling urinals and needing help to get out of bed. Another resident, who was cognitively intact but dependent on staff for toilet hygiene, had their call light ignored for 10 minutes while staff engaged in personal conversations at the nurse's station. The issue of delayed call light response was a recurring concern among residents, as evidenced by the Resident Council President's complaints. Despite raising the issue in council meetings over several months, no improvements were observed. The council minutes consistently documented residents' dissatisfaction with the call light response times, highlighting a systemic issue within the facility. Additionally, a former resident expressed frustration with the facility's acceptance of a 20-minute response time as satisfactory, emphasizing the urgency of assistance for needs such as using the bathroom. Family members of residents also reported grievances related to call light response times. One spouse found their partner in a state of neglect, covered in feces and soaked in urine, after waiting nearly 20 minutes for assistance. Another family member reported difficulties in reaching floor staff via phone, with their relative repeatedly calling for help without a response. The facility's policy on call light use was not effectively implemented, as staff failed to acknowledge and respond to call lights in a timely manner, leading to significant deficiencies in resident care.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, R2 and R74, which is a deficiency in accommodating the needs of residents. On July 9, 2024, R74 was observed sitting on the edge of her bed doing exercises with a Physical Therapy Assistant, and her call light was out of reach, hanging over a wooden dividing wall about two feet away. R74, who is cognitively intact and requires limited assistance for upper body activities, stated that she could not call for help as the call light had been out of reach for many days. Her medical history includes repeated falls, and she had previously demonstrated the use of call lights successfully. Similarly, on the same day, R2 was observed sitting in her wheelchair next to her bed, appearing anxious and searching for her call light, which was found lying under her bed on the floor. R2 is also cognitively intact and requires substantial assistance with lower body activities. Her medical history includes repeated falls, difficulty in walking, and morbid obesity. The Director of Nursing confirmed that all patients must have call lights within reach, and room rounds are conducted every couple of hours to ensure this. The facility's policy, revised in January 2024, mandates that staff ensure call lights are within reach for residents who can use them each time they leave the room.
Failure to Maintain Comfortable and Lit Environment
Penalty
Summary
The facility failed to provide a comfortable and appropriately lit environment for a resident, identified as R19, whose cognition is intact according to her Minimum Data Set. R19 reported that her heating and air conditioning unit, as well as her over bed light, had been broken for at least eight weeks. Despite notifying the staff multiple times and having work orders submitted, the issues remained unresolved. During an observation, the surveyor noted that the heating and air conditioning unit was set to 54 degrees but was barely cooling, and the over bed light did not turn on, resulting in dim lighting in the room. The Director of Environmental Services, V11, who has been working at the facility for three months, stated that he was unaware of the issues with R19's room. He acknowledged that any non-functioning light should be fixed immediately and mentioned that he had informed management about the need for new fixtures in some rooms a month prior. The facility's Work Order Report showed that R19 had reported the issues on five occasions, but they were not addressed within a reasonable timeframe as per the facility's policy. The Administrator, V1, confirmed that maintenance is responsible for reviewing all work orders.
Failure to Conduct Level II PASARR Evaluation for Resident with New Mental Disorder
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR evaluation and determination after the resident was diagnosed with a newly evident mental disorder. The resident, identified as R38, was admitted with a primary diagnosis of Type 2 Diabetes Mellitus and had an OBRA screening completed in 2019, which did not suspect mental illness. However, the resident was later diagnosed with a Psychotic Disorder with Delusions in December 2019 and Recurrent Major Depressive Disorder in June 2021. Despite these new diagnoses, the facility did not initiate a Level II PASARR evaluation as required by their policy. Interviews with facility staff revealed a lack of understanding regarding the requirement for a Level II PASARR evaluation following a new mental illness diagnosis after admission. The Admissions Director was unsure if a Level II PASARR was necessary in such cases, and the Administrator incorrectly stated that PASARR is only conducted at the point of entry. The facility's policy, however, mandates a Level II review for residents with newly evident serious mental disorders. The resident's care plan indicated behavioral issues related to their mental health conditions, yet no referral for a Level II PASARR was made, highlighting a deficiency in the facility's adherence to its own policy and regulatory requirements.
Improper Blood Glucose Monitoring Procedure
Penalty
Summary
The facility failed to adhere to professional standards of care during blood glucose monitoring for two residents, R54 and R84. On July 9, 2024, a registered nurse (RN) performed blood glucose checks on these residents but did not follow the correct procedure. Instead of using a gauze to wipe the first drop of blood after pricking the finger, the RN used an alcohol wipe, which is against the facility's policy. This action was observed during the monitoring of R54, who has type 2 diabetes mellitus and requires blood glucose checks before meals and at bedtime. The RN obtained a blood sugar reading of 209 mg/dL for R54. Similarly, the RN repeated the same incorrect procedure for R84, who also has type 2 diabetes mellitus. The initial blood sugar reading for R84 was 'High,' prompting a recheck, which resulted in a reading of 600 mg/dL. The facility's Director of Nursing acknowledged that the staff had been previously in-serviced on the correct procedure, which involves using a gauze instead of an alcohol wipe to avoid inaccurate results. The facility's policy and competency validation for blood glucose monitoring emphasize the importance of allowing the puncture site to dry and using gauze to wipe the first drop of blood.
Failure to Provide Adequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent falls for a resident identified as R14. On July 9, 2024, R14, who was at high risk for falls, experienced a fall when attempting to transfer from her wheelchair to the toilet. R14 had used the call light to request assistance but reported that it was not answered for an hour, leading her to attempt the transfer independently. During this attempt, she fell and injured her right hip. Observations noted that R14's bed was not in a low position, which could have contributed to the difficulty in managing her needs safely. The facility's Director of Nursing (DON) and Administrator both stated that residents should have call lights within reach and receive timely assistance from staff. However, the incident report and R14's care plan, which identified her as a high fall risk, indicated that her needs were not anticipated or met, resulting in the fall. The facility's fall prevention policy, reviewed in May 2024, mandates that residents receive adequate supervision and assistive devices to prevent accidents, which was not adhered to in this case. The incident was documented in R14's progress notes, but there was no detailed description of the event aside from notifying her emergency contact.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to manage a resident's pain effectively, resulting in the resident experiencing severe pain rated at 10 out of 10. The resident, who is cognitively intact, reported going over 24 hours without receiving her prescribed Percocet medication, which was intended for severe pain management. The resident's care plan included interventions to anticipate and respond immediately to any complaint of pain, yet she was informed by a nurse that the facility was out of her medication and waiting for a pharmacy delivery. The resident's records showed she was regularly receiving Percocet, averaging 5-6 doses a day, but there was a gap of over 27 hours between doses on 7/7/2024 and 7/9/2024. The facility's Medication Administration Record (MAR) indicated that the resident received her last dose of Percocet on 7/7/2024 at 11:01 PM, and the next dose was not administered until 2:45 AM on 7/9/2024. During this period, the resident was given acetaminophen for pain rated at 9, which was not aligned with the prescribed use for mild pain. The facility's policy on pain management emphasized the responsibility of clinical staff to assess and manage pain effectively, yet the documentation showed inconsistencies in pain evaluation and medication administration, contributing to the resident's unmanaged pain.
Expired and Spoiled Food Found in Resident's Refrigerator
Penalty
Summary
The facility failed to maintain proper food safety standards in a resident's personal refrigerator, leading to a deficiency. During an initial tour, a surveyor observed expired and spoiled food items in the refrigerator of a resident who was cognitively intact, with a BIMS score of 15. The items included cartons of vanilla low-fat yogurt with past best-by dates and plastic bags containing slices of ham and cheese that emitted a foul odor and had visible mold. The resident expressed surprise that the expired items were still present, as they believed staff checked the refrigerator daily. The facility's policy requires staff, including nurses and CNAs, to ensure expired food is removed, but this was not adhered to in this instance.
Incontinence Care Deficiency in LTC Facility
Penalty
Summary
The facility failed to provide appropriate toileting hygiene for residents requiring assistance with incontinence care. Observations revealed that multiple residents were found wearing two incontinence briefs, contrary to the facility's policy of using only one brief. This practice was observed in four residents, who were part of a sample of five reviewed for activities of daily living. The residents involved had various medical conditions, including cognitive impairments and physical dependencies, necessitating substantial assistance from staff for toileting hygiene. One resident, who was cognitively intact, reported waiting over an hour for incontinence care and noted that staff used two briefs to prevent overflow. Staff interviews confirmed that residents should be checked every two to three hours and only one brief should be used. However, there was inconsistency in practice, with some staff attributing the use of two briefs to the night shift or family preferences, although no documentation supported these claims in the residents' care plans. The facility's Director of Nursing acknowledged the issue, stating that staff should educate residents and families on the risks of using two briefs, such as skin breakdown and urinary tract infections. Despite this, the care plans for the affected residents did not document any preference for wearing two briefs, indicating a lack of adherence to the facility's incontinence care policy, which aims to keep residents dry, comfortable, and prevent skin breakdown.
Insulin Administration Errors
Penalty
Summary
The facility failed to administer insulin as ordered for a resident with type 2 diabetes mellitus, diabetic neuropathy, hyperglycemia, congestive heart failure, cardiac pacemaker, hypertension, and chronic kidney disease stage 3. The resident, who was cognitively intact, reported that nurses administered insulin after meals instead of before, as prescribed. The resident's Physician Order Sheet indicated sliding scale Humalog insulin was to be given before meals, but the staff administered it post-meal, leading to uncontrolled blood glucose levels. On one occasion, the resident's blood glucose was 180 mg/dL in the morning, and the nurse administered insulin late, after breakfast, at 9:46 AM instead of the scheduled 7:30 AM. The nurse admitted to forgetting to administer the sliding scale dose and corrected it later, which was not in accordance with the prescribed schedule. The Medication Administration Audit Report showed discrepancies in the timing of insulin administration, with doses being signed off late. The Director of Nursing acknowledged that insufficient insulin could lead to elevated blood glucose levels, and the Medical Doctor emphasized the importance of administering insulin within a short period around meals. The facility's policies required medications to be administered as ordered, but the staff failed to adhere to these guidelines, resulting in significant medication errors.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
